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General Medicine > Orthopaedics > Flashcards

Orthopaedics Flashcards

1
Q

What % of back pain is due to mechanical back pain?

A

85 - 90%

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2
Q

Causes of mechanical back pain

A
  • trauma
  • muscular / ligamentous pain
  • fibrositic nodulosis
  • postural back pain (sway back)
  • lumbar spondylosis
  • facet joint syndrome
  • lumbar disc prolapse
  • spinal and root canal stenosis
  • spondylolisthesis
  • disseminated idiopathic skeletal hyperostosis
  • fibromyalgia
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3
Q

Red flags in back pain history

A
  • Serious trauma / fall from height
  • minor trauma in osteoporosis
  • age < 20 or > 50 at onset
  • history of cancer / drug abuse / HIV / immunosuppression / prolonged corticosteroids
  • constitutional symptoms - fever, chills, weight loss
  • pain worse when supine
  • severe pain at night
  • thoracic pain
  • constant and progressive pain
  • severe morning stiffness
  • patient unable to walk / self care
  • saddle anaesthesia
  • recent onset problems with bladder and bowels
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4
Q

What are waddel’s signs used for

A

Used to indicate non-organic psychological component to chronic back pain

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5
Q

What are Waddel’s signs

A
  • Superficial non-anatomical tenderness
  • overreaction
  • pain on axial loading
  • pain on passive rotation
  • straight leg raise test discrepancy between supine and standing
  • non-dermatomal sensory loss
  • give-way weakness
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6
Q

Red flags on back pain examination

A
  • structural deformity
  • severe / progressive neurological deficit
  • anal sphincter laxity
  • peri-anal / perineal laxity
  • major motor weakness
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7
Q

Symptoms suggesting cauda equina syndrome

A 
Bladder dysfunction (retention +/- overflow) 
Sphincter disturbance
Saddle anaesthesia 
Lower limb weakness
Gait disturbance
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8
Q

Investigation of back pain

A 
Spinal x-ray - if neuro syx, 50yo, worse at night/morning, systemic syx
MRI - better for neuro
CT -better for bone
Bone scan - for infection / malignancy
FBC, ESR, CRP - for infection 
LFTS - Paget's disease, bony mets
PSA - prostate ca
CXR - lung ca
USS - renal stones, pancreatitis, leaking AAA
endoscopy - posterior ulcer
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9
Q

Risk factors for recurrent mechanical back pain

A 
Female
^ age
Job dissatisfaction
Pre-existing widespread chronic pain
Psychological distress - depression / anxiety
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10
Q

Types of trauma that may cause mechanical back pain

A 
Lifting
Sports
Fall
RTA 
occupation
Housework 
Sudden jolts 
Gardening
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11
Q

What are fibrositic nodules

A

Tender nodule in a muscle. Usually buttock / along iliac crests
Causes unilateral or bilateral low back pain.
Radiates to buttock and posterior thigh.

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12
Q

In whom is postural back pain most common

A

Pregnancy
Obesity
Muscle weakness

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13
Q

What is sway back

A

Postural back pain

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14
Q

What disc changes occur in spondylosis

A

Changes in disc gel - breaks up, shrinks, loss of compliance
Surrounding fibrous zones develop circumferential fissures
Discs become thinner and less compliant

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15
Q

What is facet joint syndrome

A

Arthritic changes and inflammation of facet joints

May be secondary to spondylosis

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16
Q

Symptoms of facet joint syndrome

A

Lower back pain - worse on bending forward + on straightening from flexion.
Radiation to buttocks
Unilateral or bilateral

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17
Q

Management of facet joint syndrome

A

Diagnostic injection of LA into facet joint.
Then corticosteroid injection into joint

Physiotherapy
Weight loss

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18
Q

What happens in disc herniation (prolapse)

A

Herniation of the nucleus pulposus (gelatinous centre part) through the annulus fibrosus (fibrocartilaginous outer layer)

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19
Q

What is spondylolisthesis

A

Slipping of one vertebral disc forward over the lower one

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20
Q

In what age group is spondylolisthesis most common

A

Adolescents / young adults

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21
Q

What happens in disseminated (diffuse) idiopathic skeletal hyperostosis?

A

Bony overgrowths + ligamentous ossification

Characterised by flowing calcification over the anterolateral vertebrae

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22
Q

What is Forrestier’s disease

A

disseminated (diffuse) idiopathic skeletal hyperostosis

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23
Q

What is fibromyalgia

A

A syndrome of long-term widespread body pain - affects joints, muscles, tendons and soft tissues.

Linked to fatigue, sleep problems, depression, anxiety, headaches

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24
Q

What spinal fracture is more common in osteoporosis?

A

Vertebral crush fracture

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25
Q

What causes a widows stoop

A

Increased thoracic kyphosis due to multiple osteoporotic vertebral fractures

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26
Q

How do you diagnose osteoporotic crush fractures

A

X-ray - loss of anterior vertebral body height and wedging.

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27
Q

Tx of osteoporotic crush fractures

A

Bed rest and analgesia - until pain subsides
Gradual mobilisation
May need hospitalisation - IV bisphosphonates or SC calcitonin.

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28
Q

What do yellow flags signify

A

Psychological barriers to active rehabilitation and risks of chronicity.

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29
Q

Yellow flags in back pain include:

A 
Belief pain and activity are harmful
Sickness behaviours
Social withdrawal 
Low / negative mood / anxiety
Problems at work / job dissatisfaction
Compensation / claims
Lack of family support
Inappropriate expectation of tx
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30
Q

What % of the general population have a bulging disc on MRI

A

Upto 79%

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31
Q

What % of people with back pain return to their GP within 3m

A

> 29%

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32
Q

Risk factors for osteoarthritis

A 
>65yo
Female (usually more severe - but prevalence = in both sexes)
Genetic
Obesity
Joint injury
Muscle weakness
Meniscal damage
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33
Q

Radiological features of osteoarthritis

A

Joint space narrowing
Osteophyte formation
Bone cysts
Sclerosis

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34
Q

Features suggestive of osteoarthritis

A

Pain - exacerbated by activity, relieved by res
Stiffness - transient, after rest / in morning
Reduced movement
Swelling
Crepitus
Increased age

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35
Q

Common sites of osteoarthritis

A

Hands
Knees
Hips

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36
Q

Management of osteoarthritis

A 
Weightloss
Appropriate footwear
Physiotherapy 
NSAIDS / opiates 
Effusion aspiration
surgery - osteotomy / joint replacement
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37
Q

Location of Hebredens nodes

A

distal interphalangeal joints

In osteoarthritis

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38
Q

Location of Bouchards nodes

A

Proximal interphalangeal joints

In osteoarthritis

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39
Q

Risk factors for rheumatoid arthritis

A

Female:male 3:1
Age 40-60
Family history
Smoking

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40
Q

Common deformities in RA

A

Swan neck
Boutonnière
Z thumb
Ulnar deviation

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41
Q

Where is the olecranon bursa

A

Over the ulna at the posterior tip of the elbow

Near the surface. Therefore, often exposed to trauma.

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42
Q

Syx of olecranon bursitis

A

Focal swelling over tip of elbow +/- pain
Pain may be exacerbated by pressure
Onset may date from trauma - onset without trauma suggests infection.

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43
Q

Signs of olecranon bursitis

A 
Well demarcated swelling 
Red
Warm
Skin may show contusion or abrasion. 
Movement decreased at end of flexion - due to pain.
44
Q

What does elbow pain on passive or active movement suggest

A

Possible olecranon process fracture

45
Q

DDX of olecranon bursitis

A 
Fractured olecranon process
Haemarthrosis
Inflammatory arthropathy e.g RA
Crystal arthropathy e.g. Gout
Autoimmune disease
Ehlers Danlos Syndrome
Synovial cyst
46
Q

Investigations for olecranon bursitis

A 
FBC - WCC
Uric acid levels 
CRP / ESR
RF
Plain x-ray if hx of trauma
Aspiration of bursa
47
Q

What are gout crystals made of

A

Monosodium urate crystals

48
Q

What are pseudogout crystals made of

A

Calcium pyrophosphate
OR
Hydroxyapatite

49
Q

Management of olecranon bursitis

A

RICE - rest, ice, compression, elevation
Antibiotics if septic
Aspiration
Steroid instillation

50
Q

Possible complications of olecranon bursitis

A

Septicaemia
Osteomyelitis
Persistent pain

51
Q

Causes of non-specific neck pain

A 
Poor posture
Neck strain
Sports
Occupation
Anxiety and depression
52
Q

Causes of neck pain

A 
Posture, injuries etc
RA, OA, Fibromyalgia, osteoarthritis
Cervical spondylosis
Cervical intervertebral disc prolapse
Spinal stenosis
Osteomyelitis
Whiplash / trauma
CV, Resp, upper GI problems
53
Q

Rick factors for neck pain

A 
Neck posture
Arm posture
Prolonged sitting 
Twisting / bending of the body
Hand / arm vibration
Excessive pillows
Excessive concerns
Issues of injury compensation 
Psychosocial problems
54
Q

What is cervical radiculopathy

A

Compression or injury to a nerve root in the c- spine

55
Q

Syx of cervical radiculopathy

A

Pain - unilateral neck, shoulder or arm
Motor dysfunction - weakness
Sensory deficit - altered sensation, paraesthesia
Altered tendon reflex

56
Q

Red flags in neck pain

A

New syx 55yo
Weakness in >1 myotome
Intractable / increasing pain
Neurological syx - gait disturbance, clumsy/weak hands, loss of bladder/bowel syx
Malaise, fever, weight loss
Hx of inflammatory arthritis, cancer, TB, immunosuppression, HIV,
Lymphadenopathy
Hx of violent trauma / fall from a height
Dizziness / blackouts

57
Q

DDX of neck pain

A

Disc prolapse
Tonsillitis
C-spine injury –> muscle strain, dislocation, fracture
Vertebral osteomyelitis
Cervical lymphadenopathy due to cancer
Eye disorders
Dystonia secondary to stroke, encephalitis etc
Dystonic reaction - antipsychotics, metoclopramide, cocaine
Pseudodystonia
Somatisation

58
Q

What is tunnels test + what’s it for

A

Tap over median nerve at wrist

To reproduce syx in carpal tunnel.

59
Q

What is phalens test + what’s it for

A

Hold the wrists palmar flexed together for 1 min

To reproduce syx in carpal tunnel

60
Q

What are the LOAF muscles

A

Lateral 2 lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis

61
Q

What is supplied by the ulnar nerve

A 
Hand muscles (except LOAF muscles) 
Sensation to ring and little finger
62
Q

Syx of chronic ulnar lesions

A

Clawing of the hand

63
Q

Do proximal or distal ulnar nerve lesions cause more marked clawing of the hand

A

Distal = more clawed

64
Q

Which cancers metastasise to bone?

A 
Lung
Breast
Thyroid
Renal
Prostate
65
Q

What part of the rotator cuff is most commonly injured?

A

Spraspinatus

66
Q

What is hypertrophic pulmonary osteoarthropathy?

A

Subperiosteal new bone formation in the long bones

Pain and painting of the anterior shin

67
Q

Presentation of posterior dislocation of the shoulder

A

Painful shoulder
Most commonly occurs after a seizure
On examination the coracoid process may be prominent

68
Q

What does a dinner fork deformity suggest?

A

Colles fracture

69
Q

Presentational De Quervain’s tenosynovitis

A

Pain on wrist adduction and flexion

Radial side of wrist

70
Q

What is an important side effect of bisphosphonates

A

Osteonecrosis of the jaw

71
Q

Features of carpal tunnel syndrome

A

Lateral 3 1/2 fingers
Pain
Paraethesia

72
Q

What does a prominent tender tibial tubercle suggest

A

Osgood-schlatter disease

73
Q

Radiological features of rheumatoid arthritis

A

Loss of joint space
Subluxation of joints
Erosions
Soft tissue swelling

74
Q

Radiological features of Paget’s disease

A

Local bone enlargement
lytic lesions with nearby sclerosis
Long bone bowing

75
Q

Radiological features of ankylosing spondylitis

A

Syndesmophytes

Bamboo spine

76
Q

X-ray appearance of Sunday speculation suggests….

A

Osteosarcoma

77
Q

X-ray appearance of onion peel sign suggests….

A

Ewings sarcoma

78
Q

What is perthes disease

A

self-limiting hip disorder
caused by ischaemia and necrosis of the femoral head.

avascular necrosis of the proximal femoral epiphysis.
Abnormal growth of the epiphysis results.
Eventual remodelling of regenerated bone.

79
Q

Classical patient with perthes disease

A 
4 - 8 year-old boy
delayed skeletal maturity.
Male to female ratio: 5:1
Rare in non-Caucasians.
Increased incidence with family history, low birthweight, abnormal pregnancy/ delivery.
80
Q

Presentation of perthes disease

A 
all movements at the hip are limited.
early phase - limited hip abduction, limited internal rotation 
 antalgic gait
Trendelenburg gait - seen late.
No history of trauma.
81
Q

Management of Perthes disease

A

Children 8yp - surgery + physio

82
Q

What does SUFE stand for?

A

Slipped upper femoral epiphyses

83
Q

Classical patient with SUFE

A

Adolescent - 10-17yo
Peak age = 13 years for boys. 11.5 years for girls.
left hip is more commonly affected than right
bilateral in 20-40%
3x more common in boys.

84
Q

Risk factors for SUFE

A 
Mechanical: local trauma, obesity.
Inflammatory conditions: neglected septic arthritis.
Hypothyroidism, 
hypopituitarism, 
growth hormone deficiency, 
pseudohypoparathyroidism.
Previous radiation of the pelvis, 
chemotherapy, 
renal osteodystrophy-induced bone dysplasia.
85
Q

Presentation of SUFE

A

Discomfort in hip, groin, medial thigh or knee during walking
pain accentuated by running, jumping, or pivoting.
Pre-slip: slight discomfort.
Acute: Severe pain - unable to walk / stand.
limp on the affected side,
external rotation of the leg.
Hip motion limited - esp internal rotation and abduction

Chronic: Mild symptoms - child able to walk with altered gait.

86
Q

Symptoms of posterolateral intervertebral disc herniation

A

Acute onset back pain

Sciatica

87
Q

Symptoms of spondylosis

A

Aching pain
Worth on activity and in the morning
Some restriction of spinal movement

No muscle spasm

88
Q

Symptoms of spinal stenosis

A

Back and leg pain on standing and walking

Relieved by sitting or bending forward

89
Q

What is discitis and who does it affect

A

Infection of the intervertebral disk

Occurs in young children

90
Q

Symptoms of discitis

A

Severe pain
Refusal of movement
Impaired mobility

91
Q

What does a palpable step on examination of the spine indicate

A

Spondylolisthesis

92
Q

What is Potts disease

A

TB of the spine

Often results in abscess formation

93
Q

Management of SUFE

A 
Avoid moving or rotating the leg. 
Do not  walk.
analgesia
Immediate orthopaedic referral.
scheduled for surgery immediately.
Surgical closure of the epiphysis - screws percutaneously.
94
Q

Presentation of an anterior dislocation of the shoulder

A

Usually caused by a fall onto the outstretched hand or shoulder.
Severe shoulder pain
Unwillingness to move arm
Flattened shoulder contour
Humeral head palpable in infra-clavicular fossa

95
Q

Most common type of shoulder dislocation

A

95% anterior

96
Q

What nerve can an anterior shoulder dislocation damage

A

Axillary nerve
Weakness of deltoid
Regimental patch numbness

97
Q

Most likely cause of severe pain on shoulder abduction >120 degrees

A

Suprasipinatus tendonitis

98
Q

Presentation of a frozen shoulder (adhesive capsulitis)

A 
Hx of minor trauma
Middle aged
Aching pain
Restricted shoulder flexion, extension, rotation and abduction
Spontaneous recovery over 12m
99
Q

What is impingement syndrome (painful arc syndrome)

A

Pain on adduction between 60-120
Due to mechanical nipping of a tender structure between the acromion and greater tuberosity.
Can be due to incomplete tear of suprasipinatus tendon, chronic suprasipinatus tendonitis, subacromial bursitis

100
Q

What 4 muscles make up the rotator cuff

A

Suprasipinatus
Infraspinatus
Subscapularis
Teres minor

101
Q

Presentation of rotator cuff tear

A

Shoulder tip pain
Local tenderness at lateral margin of acromion process.
Inability to abduct the arm
Can hold arm in abduction if passively elevated to 90degrees + due to deltoid.
Once lowered below 90 - arm drops

102
Q

Management of an intracapsular fractured neck of femur

A

Internal fixation with cannulated screw if undisplaced

Hemi-arthroplasty if displaced

103
Q

What is the classification system for femoral neck fractures

A

Garden
Type 1 - stable fracture.
Type 2 - complete but non-displaced.
Type 3 - partially displaced but still has some contact between 2 fragments.
Type 4 - completely displaced + no contact between 2 fragments.

104
Q

What are the 2 main types of hemi-arthroplasty

A

Cemented - Thompson’s

Non-cemented - Austin-Moore

105
Q

Presentation of patellar fracture

A

Knee pain
Haemarthrosis
Inability to extend knee

106
Q

Symptoms of transient synovitis

A 
Most common cause of hip pain in prepubescent children
Often follows viral infection
Suffer onset hip pain
Slight limp
Reduced range of movement
No pain at rest 
No systemic symptoms
107
Q

What causes trigger finger

A

Thickening and constriction of the mouth of the tendon sheath. The tendon beComes swollen under the sheath.
Easy to flex the finger. But difficult to extend

General Medicine (25 decks)

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